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Superior Advantage®

$31

.63 per month

per month

Individual + 1

$61.82

Individual + 2 or More

$98.42

Annual Max Year 1

$500

Annual Max Year 2

$1,000

Annual Max Year 3

$1,250

Annual Max Year 4

$1,500

Brighter Advantage®

$34

.97 per month

per month

Individual + 1

$68.85

Individual + 2 or More

$119.90

Annual Max Year 1

$750

Annual Max Year 2

$1,000

Annual Max Year 3

$1,250

Annual Max Year 4

$1,500

Teeth Whitening

COVERED

Veneers

COVERED

Braces - All Ages

COVERED

Superior Advantage®

Covered Dental Services

Delta Dental PPO℠ Network

Year One

Years Two, Three, Four or more

Annual Maximum Benefits

Contract Year

$500

$1,000 | $1,250 | $1,500

Deductible

Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)

$50 / $150

$50 / $150

Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

100%

100%

Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

50%

80%

Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

25%

50%

Orthodontia

Braces

Not Included

Not Included

Covered Dental Services

Out of Network

Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

80%

80%

Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

40%

60%

Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

10%

40%

Orthodontia

Braces

Not Included

Not Included

Annual Maximum Benefits

Contract Year

Year One $500
Years Two, Three, Four or more $1,000 | $1,250 | $1,500
Deductible

Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)

Year One $50 / $150
Years Two, Three, Four or more $50 / $150
Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

Year One 100%
Years Two, Three, Four or more 100%
Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

Year One 50%
Years Two, Three, Four or more 80%
Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

Year One 25%
Years Two, Three, Four or more 50%
Orthodontia

Braces

Year One Not Included
Years Two, Three, Four or more Not Included
Covered Dental Services

Out of Network

Year One --
Years Two, Three, Four or more --
--
Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

Year One 80%
Years Two, Three, Four or more 80%
Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

Year One 40%
Years Two, Three, Four or more 60%
Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

Year One 10%
Years Two, Three, Four or more 40%
Orthodontia

Braces

Year One Not Included
Years Two, Three, Four or more Not Included

Brighter Advantage®

Covered Dental Services

Delta Dental PPO℠ Network

Year One

Years Two, Three, Four or more

Annual Maximum Benefits

Contract Year

$750

$1,000 | $1,250 | $1,500

Deductible

Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)

$50 / $150

$50 / $150

Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

100%

100%

Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

50%

80%

Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

25%

50%

Orthodontia

Braces

Not Included

50%

Covered Dental Services

Out of Network

Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

80%

80%

Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

40%

60%

Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

10%

40%

Orthodontia

Braces

Not Included

40%

Annual Maximum Benefits

Contract Year

Year One $750
Years Two, Three, Four or more $1,000 | $1,250 | $1,500
Deductible

Per person / Per family max (contract year; applies to all services except Delta Dental PPO Diagnostic & Preventive services.)

Year One $50 / $150
Years Two, Three, Four or more $50 / $150
Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

Year One 100%
Years Two, Three, Four or more 100%
Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

Year One 50%
Years Two, Three, Four or more 80%
Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

Year One 25%
Years Two, Three, Four or more 50%
Orthodontia

Braces

Year One Not Included
Years Two, Three, Four or more 50%
Covered Dental Services

Out of Network

Year One --
Years Two, Three, Four or more --
--
Diagnostic & Preventive Services

Exams*, Cleanings*, Fluoride, Space Maintainers, Brush Biopsy, X-rays, Periodontal Maintenance

Year One 80%
Years Two, Three, Four or more 80%
Basic Services

Emergency Palliative Treatment, Sealants, Minor Restorative Services (Fillings), Simple Extractions, Other Basic Services, Adjustments & Repairs

Year One 40%
Years Two, Three, Four or more 60%
Major Services

Crown Repair, Endodontic Services, Periodontic Services, Other Oral Surgery, Major Restorative Services, Relines & Rebase, Implants, Prosthodontic Services

Year One 10%
Years Two, Three, Four or more 40%
Orthodontia

Braces

Year One Not Included
Years Two, Three, Four or more 40%

You will be charged a monthly transaction fee of $2.50. Plus $25 application fee at enrollment. Rates valid through 12/31/18.

*Limited to two per person in a 12-month period. Persons with certain medical conditions may be eligible for more.

See the Schedule of Benefits for this policy for a comprehensive explanation of services covered and not covered.

Who is eligible?

Membership is open to all Tennessee adult residents and their dependents. If you have been covered by a Delta Dental of Tennessee individual policy and drop your coverage, you cannot re-enroll for 12 months.

When do my benefits start?

Your benefits for either plan will become effective the first day of the month following receipt of application, $25 application fee, and initial premium if received on or before the 15th of the month. If received after the 15th, effective date will be the first day of the following month.

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